Prescription Transfer Form

Prescription Transfer Form

Transfer your prescription to Ella Community Pharmacy
I am requesting transfer of my prescription(s) to Ella Community Pharmacy - I would like to pick up at the following location:
Please note: Prescriptions are only transferrable if they have refills remaining and they are not expired. Additional restrictions (laws) apply for transfer of controlled substance prescriptions. (Please call the pharmacy to discuss individual details if you require the transfer of a controlled substance.)
Name

First NameLast Name
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Patient's Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com
Name of current pharmacy and location (example: Westfield Kroger - 32 & Carey Rd)
Phone Number of Pharmacy listed above
Please enter a valid phone number.Format: (000) 000-0000.
Type your prescription number(s) in the field below (please separate multiple numbers by commas):
Total Number of prescriptions you would like transferred:
Please select a date on which you would prefer to pick up your prescription(s). **NOTE: please allow at least 24 business hours for prescription transfer. If you require transfer same day - please call the pharmacy directly to make these arrangements with a pharmacy staff member.

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Please type any notes for the pharmacy staff (if any):
How did you hear about us?
If you were referred to us by a current patient, please list their name below.
Referral first and last name
Discount code
If you have a discount code for transferring - good for a percentage off our OTC items - please enter it here.
Should be Empty: